6.1 NEED FOR THE STUDY:
Multiple sclerosis (MS) is a chronic inflammatory demyelinating disease of the central nervous system (CNS). It largely affects young adults between the age of 20 and 40 years and is often referred to as “great crippler of the young adults”(1). Sir Agustus D’Este first recorded MS in 1822 (2).
There have been relatively few studies from Asia and India in particular. The reason being in India the prevalence of multiple sclerosis is very low. Early symptoms typically include minor visual disturbance and parasthesia progressing to numbness weakness and fatigue. In more advanced stages, common symptoms are gait disturbances, sensory loss, pain, visual problems, diminished cognitive functions, fatigue, spasticity, incoordination, diminished sexual capacity and bowel and bladder dysfunction. (1)
Leigh Hale, Elaine (2003) gave the effect of combined exercise program (strengthening, aerobic, balancing and stretching components) in people with MS and reported a feeling of improvement in both impairment and functional measures(3).
Kasser, Susan L et al (1999) found that balance interventions are effective in improving the balance in individuals with MS (4). This study shall be helpful in finding different aspects for treatment of multiple sclerosis. It shall be beneficial for both the patients and the therapists, as it shall explore different methods for treatment of multiple sclerosis.
6.2 HYPOTHESIS:
NULL HYPOTHESIS: There is no significant effect of the combined exercise program in improving the aerobic fitness, muscle power, balance and walking in patients with “multiple sclerosis”.
ALTERNATE HYPOTHESIS: The combined exercise program is significantly effective in the patients with “multiple sclerosis”.
6.3 REVIEW OF LITERATURE:
Pentajan &White (1999) said that MS is an incurable demyelinating neurological disease that usually affects people from early adulthood. The symptoms are numerous and commonly include fatigue, muscle weakness and psychological problems. (5)
Pentajan et al (1996) gave studies that examine the effect of aerobic exercise in people with MS. The subjects had variety of positive effects including improved cardiovascular fitness. (6)
Rhomberg, A. Virtamen et al (2004) confirmed that strength and aerobic training exercises are safe for multiple sclerosispatients and should be recommended for those with mild to moderatedisability. (7)
Leigh Hale, Elaine (2003) studied the effect of combined exercise program (strengthening, aerobic, balancing and stretching components) in people with MS and reported a feeling of improvement in both impairment and functional measures. (3)
Jo Anne, A. Howe and Michelle A. Gomperts (2006) studied the effect of aerobic training on enhancing cardiovascular fitness, muscle strength and Health Related Quality Of Life (HRQOL). (8)
L J White, S C Mc coy, V Castellano et al (2004) found that MS patients are capable of making positive adaptations to resistance training that are associated with improved ambulation and decreased fatigue. (9)
H Bjarnadottir, A D Konradsdottir, K Reynisdottir (2007) studied the effect of aerobic and strength exercises on physical fitness and quality of life in patients with MS and confirmed that brief moderate aerobic exercise improves fitness in individuals with MS. (10)
Cath Smith, Leigh Hale (2006) determined safe application of arm cranking and investigated possible effects of increased aerobic activity on cardiovascular endurance and self-efficacy in a severely disabled adult with MS using arm ergometer. (11)
De Bolt, Mc Cubbin (2004) tested the effects of resistance workout on mobility, leg power and balance directly. (12)
Kasser, Susan L et al (1999) found that balance interventions are effective in improving the balance in individuals with MS. (4)
D. Cattaneo et al studied several tests of static and dynamic balance in subjects with MS and concluded that “Berg Balance Scale, Timed up and go test, Dynamic Gait Index and Activity specific Balance Confidence” have acceptable concurrent validity. (13)
Cole et al (1994) showed that TUG test, Berg Balance Scale and 10-meter walk test have been used extensively in neurological rehabilitation and have found to be reliable and valid. (14)
Kurtze (1983) gave the “Kurtze Expanded Disability Status Scale” for grading of disability. The scale is valid for classification of mild to moderate disability. (15)
Berg et al (1992) gave the “Berg Balance Scale” for measurement of balance. (1)
Schwartz et al gave the Multiple Sclerosis self efficacy scale (1996) and Performance scale (1999) as self reported measures of impairment and ability in patients with “multiple sclerosis”.(16,17)
6.4 OBJECTIVE OF THE STUDY: To study the effect of combined exercise program of aerobic training, strength training and balance training in improving the aerobic fitness, muscle power, balance and walking in patients with “multiple sclerosis”.
MATERIALS AND METHODOLOGY:
7.1 Source of data:
M.S. Society, Bangalore.
NIMHANSHospital, Bangalore
7.2 Methods of Data collection: -
i) Inclusion criteria
Age 25 – 60 years.
Both sexes.
Confirmed diagnosis of clinically proven MS.
Patient possessing sufficient cognitive ability to understand the instructions given.
Independently mobile patients.
Medically stable patients.
ii) Exclusion criteria:
Age more than 60 years.
Medically unstable patients.
Patient with cognitive dysfunction so that he/she cannot understand the instructions given.
Immobile patients.
Patients with any other medical problem with MS, that can affect the study like, hypertension, diabetes, etc.
Other conditions that mimic MS.
iii) Research design: Clinical study with an experimental group with pre test and post test evaluation of dependent variable measures.
iv) Sampling technique: Randomized sampling
v) Sample size: 10 subjects. Convenient sampling.
vi) Materials used:
B.P. Apparatus.
Therabands.
Weight cuffs.
vii) Scales used:
Berg’s balance scale. (1)
Kurtze’s expanded disability status scale. (15)
MS self-efficacy scale. (16)
Performance scale. (17)
viii) Outcome measures:
Aerobic fitness.
Muscle power.
Balance.
Walking ability.
Ability to perform the activities of daily living (ADL), which the patient was not able to do or had difficulty in performing earlier.
Methodology:
The training program includes strengthening, aerobic and balancing exercises that will be given to the patients for a period of 12 weeks under the supervision of a physiotherapist. An informed consent of the patients will be taken for the treatment program. In this duration of 12 weeks, the patients shall be evaluated every 4 weekly i.e. at the end of 4th week, 8th week and 12th week.
7.3 Interventions to be conducted on the participants
Treatment given:
The following activities will be given to the patients in 3 sessions per week.
Aerobic training will include independent cycling against progressively increasing resistance and 10-meter walk test.
Balance training will include different balancing exercises according to patient’s ability. (3)
Balancing on both legs.
Balancing on 1 leg.
Unaided walking.
Fast walking.
Side walking.
Walking with changing directions.
Walking on uneven surfaces.
Stair climbing and descending.
Walking up and down on incline.
Walking with another task or dual tasking.
Sit to stand.
Lying to standing.
Squatting.
Strengthening exercises will include resisted exercises depending on the muscle power of the patients. Resistance will be applied where possible in the form of weight cuffs, body weight, and therabands or manually by therapist. The exercises will include both open and closed kinamatic chain exercises. (3)
10 repetitions shall be given for each exercise.
Statistical Analysis: -
Homogenecity of groups for age, gender, severity of multiple sclerosis is tested by using “Paired t test”. Result will be analyzed using “Paired t test” with 5% level of significance.
7.4 Ethical Clearance:
As my study includes human subjects, ethical clearance is obtained from research and ethical committee of the institution.
REFERENCES
- Susan B. O’ Sullivan. Physical rehabilitation assessment and treatment. 5th Ed. Jaypee brothers, New Delhi.
- Darcy Ann Umphered. Neurological rehabilitation. 3rd Ed, Mosby publication.
- Leigh Hale, Jan Piggot, Andy Littmann, Steve Tumitty (2003). The effect of combined exercise program for people with multiple sclerosis. A case series. NZ Journal of physiotherapy, Nov-2003, Vol-31-3, 130-138.
- Kasser, Susan L, Rose, Debra L (1999) Balance training for adults with multiple sclerosis. Multiple case series. Neurology journal 1999.
- Pentajan JH and white AT (1999). Recommendation for physical activity with multiple sclerosis. Sports medicine 27, 3:179-191.
- Pentajan JH, Gappaier E, White AT, Spencer Mk et al (1996). Impact of aerobic training on fitness and quality of life in multiple sclerosis. Annuals of neurology 39:432-441.
- Romberg. J Ruutiainen S.L. Karppi et al (2004), Effect of a 6 Months exercise program on patient with MS, A Randomized study. Neurology 2004:63:2034 - 2038
- Joe-AnneA. Howe and Michelle A. Gomperts (2006). Aerobic testing and training for person with MS. A review with clinical recommendations. PT Canada, Vol: 50, No: 4: 259- 270.
- LJ White, SC MC Coy. V Castello G Gutierrez, G. Stevens, J.E.Walter, G.A. at al (2004). Resistance training improves strength and functional capacity in person with multiple sclerosis 2004. Multiple sclerosis 10: 668-674.
- Bjarnadottir, A.D.Konrads Dottir, K. Reynisdottir, E. Olafsson (2007). Multiple sclerosis and brief moderate exercise. A randomized study. MS Vol.13-6, 776-782.
- Cath smith Leigh hales (2006) Arm cranking: An exercise intervention for a severely disabled adult with MS. NZ journal of PT. Nov2006 Vol134:3 172-178.
- De Bolt, L.S. & Mc Cubbin JA (2004). The effect of home based resistance exercise on balance, power and mobility in adult with MS. Archive of physical and medical rehabilitation 85:290-297.
- Cattaneo D.Regolae, Meotti, Validity of six-balance disorder scale person with MS.
- Cole B, Finch E, Gowland C and Mayo N (1994). Physical rehabilitation outcome measures. Canadian physiotherapy association.
- Kurtze JF (1983). Rating neurological impairment in multiple sclerosis an expanded disability status scales (EDSS). Neurology 1983:33:1444-52.
- Schwartz CE, Coulthard, Morril, Geng Q et al (1996). Measuring self-efficacy in people with multiple sclerosis a validation study. Archive of physical medicine and rehabilitation 77:394-398.
- Schwartz CE, Volmer T and Lee H (1999). Reliability and validity of two self reported measure of impairment and disability for multiple sclerosis. Neurology, 52:63-70.